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June 2017

Tower International selects Reference Based Benefits feature for some member segments

Beginning July 1, 2017, Tower International has selected the Reference Based Benefits feature for some of its employees. This benefit feature sets a maximum (reference) price Tower International will pay for select services for its employees. And RBB encourages members to use online tools to help compare health care facilities based on costs.

We’ll include information for Tower International in the July billing chart.

How can I tell a member has RBB?
Tower International employees have group number 71379 on their member ID cards, with a prefix of TOV. Additionally, when you look up member benefits and eligibility, verbiage appears on web-DENIS that says the contract has Reference Based Benefits.

Where can I get information about the member’s liability?
For more information about the member’s liability after a given service, go to web-DENIS and check your patient’s benefits and eligibility to see the associated RBB information. This will include the reference price. The member pays for his or her standard cost share and any difference between the Blue Cross Blue Shield of Michigan allowed amount and the reference price.

Note: This feature affects member cost share, not what Blue Cross will pay health care providers for services. In-network providers can expect to receive contracted rates on all procedures.

What services does this apply to?
Tower International has selected to apply RBB to the following services:

  • Inpatient surgeries — hip and knee replacement
  • Outpatient surgeries — bariatric surgery, cataract removal, carpal tunnel repair, ACL repair, shoulder arthroscopy (and select others)

The benefits and eligibility section on web-DENIS has a full list of affected services.

How does this work?
When you charge eligible services below the reference price, Blue Cross will pay the allowed amount minus any member liability. For those charges that may exceed the reference price, the member pays his or her standard cost share, plus any difference between the Blue Cross allowed amount and the reference price.

For example: If the reference price is $500 for a bunionectomy and the Blue Cross allowed amount is $700, then Blue Cross pays up to $500, less the member’s standard cost share, for the procedure. The member pays for his or her standard cost share on the part up to $500, plus the $200 difference between the Blue Cross allowed amount and the reference price.

For more information, see the Reference Based Benefits article published in the November 2016 issue of The Record.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
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